Posterior vitreous detachment, retinal breaks, and lattice degeneration.

Complete Summary GUIDELINE TITLE Posterior vitreous detachment, retinal breaks, and lattice degeneration. BIBLIOGRAPHIC SOURCE(S) American Academy of Ophthalmology Retina Panel, Preferred Practice Patterns Committee. Posterior vitreous detachment, retinal breaks, and lattice degeneration. San Francisco (CA): American Academy of Ophthalmology (AAO); 2003. 17 p. [55 references] GUIDELINE STATUS This is the current release of the guideline. This guideline updates a previous version: American Academy of Ophthalmology (AAO), Preferred Practice Patterns Committee, Retina Panel. Management of posterior vitreous detachment, retinal breaks, and lattice degeneration. San Francisco (CA): American Academy of Ophthalmology (AAO); 1998. 24 p. All Preferred Practice Patterns are reviewed by their parent panel annually or earlier if developments warrant. COMPLETE SUMMARY CONTENT SCOPE METHODOLOGY - including Rating Scheme and Cost Analysis RECOMMENDATIONS EVIDENCE SUPPORTING THE RECOMMENDATIONS BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS QUALIFYING STATEMENTS IMPLEMENTATION OF THE GUIDELINE INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES IDENTIFYING INFORMATION AND AVAILABILITY DISCLAIMER SCOPE DISEASE/CONDITION(S) Precursors to rhegmatogenous retinal detachment and the following related entities: Posterior vitreous detachment 1 of 13

Retinal break without detachment Multiple retinal breaks without detachment Horseshoe tear without detachment Operculated break without detachment Round hole without detachment Retinal dialysis Lattice degeneration of the retina GUIDELINE CATEGORY Diagnosis Evaluation Management Treatment CLINICAL SPECIALTY Ophthalmology INTENDED USERS Health Plans Physicians GUIDELINE OBJECTIVE(S) To prevent visual loss and functional impairment related to retinal detachment and to maintain quality of life by addressing the following goals: Identify patients at risk for rhegmatogenous retinal detachment (RRD) Examine patients with symptoms of acute posterior vitreous detachment (PVD) to detect and treat significant retinal breaks Manage patients at high risk for developing retinal detachment Educate high-risk patients about symptoms of posterior vitreous detachment, retinal breaks, and retinal detachments and about the need for periodic follow-up TARGET POPULATION Individuals with symptoms or signs suggestive of posterior vitreous detachment (PVD), retinal breaks, vitreous hemorrhage, or retinal detachment Asymptomatic individuals with an increased risk for retinal detachment INTERVENTIONS AND PRACTICES CONSIDERED Diagnosis/Evaluation 1. Comprehensive adult eye examination and history 2. Examination of the vitreous for detachment, pigmented cells, hemorrhage, and condensation 2 of 13

3. Peripheral fundus examination with scleral depression 4. B-scan ultrasonography Treatment 1. Cryotherapy 2. Laser photocoagulation Management 1. Follow-up evaluations 2. Patient education MAJOR OUTCOMES CONSIDERED Identification of patients at risk Prevention of visual loss and functional impairment Maintenance of quality of life METHODOLOGY METHODS USED TO COLLECT/SELECT EVIDENCE Searches of Electronic Databases DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE A detailed MEDLINE literature search for articles in the English language was conducted on the subject of posterior vitreous detachment, retinal breaks, and lattice degeneration for the years 1997 to 2002. NUMBER OF SOURCE DOCUMENTS Not stated METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE Weighting According to a Rating Scheme (Scheme Given) RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE Ratings of Strength of Evidence I. Level I includes evidence obtained from at least one properly conducted, welldesigned randomized, controlled trial. It could include meta-analyses of randomized controlled trials. II. Level II includes evidence obtained from the following: Well-designed controlled trials without randomization 3 of 13

III. Well-designed cohort or case-control analytic studies, preferably from more than one center Multiple-time series with or without the intervention Level III includes evidence obtained from one of the following: Descriptive studies Case reports Reports of expert committees/organization Expert opinion (e.g., Preferred Practice Pattern panel consensus) METHODS USED TO ANALYZE THE EVIDENCE Systematic Review DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE Not stated METHODS USED TO FORMULATE THE RECOMMENDATIONS Expert Consensus DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS The results of a literature search on the subject of posterior vitreous detachment, retinal breaks, and lattice degeneration were reviewed by the Retina Panel and used to prepare the recommendations, which they rated in two ways. The panel first rated each recommendation according to its importance to the care process. This "importance to the care process" rating represents care that the panel thought would improve the quality of the patient s care in a meaningful way. The panel also rated each recommendation on the strength of the evidence in the available literature to support the recommendation made. RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS Ratings of Importance to Care Process Level A, most important Level B, moderately important Level C, relevant but not critical COST ANALYSIS A formal cost analysis was not performed and published cost analyses were not reviewed. METHOD OF GUIDELINE VALIDATION Internal Peer Review 4 of 13

DESCRIPTION OF METHOD OF GUIDELINE VALIDATION These guidelines were reviewed by Council and approved by the Board of Trustees of the American Academy of Ophthalmology (September 2003). All Preferred Practice Patterns are reviewed by their parent panel annually or earlier if developments warrant and updated accordingly. RECOMMENDATIONS MAJOR RECOMMENDATIONS The ratings of importance to the care process (A, B, C) and the ratings for strength of evidence (I, II, III) are defined at the end of the "Major Recommendations" field. Diagnosis The initial evaluation of a patient with risk factors or symptoms includes all features of the comprehensive adult medical eye evaluation, with particular attention to those aspects relevant to posterior vitreous detachment (PVD), retinal breaks, and lattice degeneration. History Symptoms of PVD [A:I] Family history [A:II] Prior eye trauma, including surgery [A:II] Myopia [A:II] History of cataract surgery [A:II] Examination Examination of the vitreous [A:III] for detachment, pigmented cells, hemorrhage, and condensation Peripheral fundus examination with scleral depression [A:III] There are no symptoms that can reliably distinguish PVD with an associated retinal break from PVD without an associated retinal break; therefore, a peripheral retinal examination is required. [A:III] The preferred method of evaluating peripheral vitreoretinal pathology is with indirect ophthalmoscopy combined with scleral depression. Diagnostic Tests If it is impossible to evaluate the peripheral retina, B-scan ultrasonography should be performed to search for retinal tears or detachment and for other causes of vitreous hemorrhage. [A:II] Treatment 5 of 13

The table below summarizes recommendations for management. Type of Lesion Acute symptomatic horseshoe tears Acute symptomatic operculated tears Traumatic retinal breaks Asymptomatic horseshoe tears Asymptomatic operculated tears Asymptomatic atrophic round holes Asymptomatic lattice degeneration without holes Asymptomatic lattice degeneration with holes Asymptomatic dialyses Fellow eyes with atrophic holes, lattice degeneration, or asymptomatic horseshoe tears Treatment Treat promptly [A:II] Treatment may not be necessary [A:III] Usually treated [A:III] Usually can be followed without treatment [A:III] Treatment is rarely recommended [A:III] Treatment is rarely recommended [A:III] Not treated unless PVD causes a horseshoe tear [A:III] Usually does not require treatment [A:III] No consensus on treatment and insufficient evidence to guide management No consensus on treatment and insufficient evidence to guide management Treatment of peripheral horseshoe tears should be extended well into the vitreous base, even to the ora serrata. [A:II] The surgeon should inform the patient of the relative risks, benefits, and alternatives to surgery. [A:III] The surgeon has the responsibility for formulating a postoperative care plan and should inform the patient of these arrangements. [A:III] Follow-up The guidelines in the table below are for routine follow-up in the absence of additional symptoms. Patients with no positive findings at the initial examination should be seen at the intervals recommended in the Comprehensive Adult Medical Eye Evaluation Preferred Practice Pattern (PPP). [A:III] All patients with risk factors should be advised to contact their ophthalmologist promptly if new symptoms such as flashes, floaters, peripheral visual field loss, or decreased visual acuity develop. [A:II] 6 of 13

Type of Lesion Symptomatic PVD with no retinal break Acute symptomatic horseshoe tears Acute symptomatic operculated tears Follow-up Interval Depending on symptoms, risk factors, and amount of vitreous traction, patients should be followed in 1 to 6 weeks 1 to 2 weeks after treatment, then 4 to 6 weeks, then 3 to 6 months, then annually 2 to 4 weeks, then 1 to 3 months, then 6 to 12 months, then annually Traumatic retinal breaks 7 to 14 days after treatment, then 4 to 6 weeks, then 3 to 6 months, then annually Asymptomatic horseshoe tears Asymptomatic operculated tears Asymptomatic atrophic round holes Asymptomatic lattice degeneration without holes Asymptomatic lattice degeneration with holes Asymptomatic dialyses 1 to 4 weeks, then 2 to 4 months, then 6 to 12 months, then annually 2 to 4 weeks, then 1 to 3 months, then 6 to 12 months, then annually Annually Annually Annually If untreated, 1 month, then 3 months, then 6 months, then every 6 months If treated, 1 to 2 weeks after treatment, then 4 to 6 weeks, then 3 to 6 months, then annually Fellow eyes with atrophic holes, lattice degeneration, or asymptomatic horseshoe tears Every 6 to 12 months History Visual symptoms [A:I] Interval history of eye trauma, including intraocular surgery [A:I] 7 of 13

Examination Measurement of visual acuity [A:III] Evaluation of the status of the vitreous, with attention to the presence of pigment or syneresis [A:II] Examination of the peripheral fundus with scleral depression [A:II] B-scan ultrasonography if the media is opaque [A:II] Provider It is essential that ancillary clinical personnel be familiar with the symptoms of PVD and retinal detachment so that symptomatic patients can gain prompt access to the health care system. [A:II] Patients with symptoms of possible or suspected PVD or retinal detachment and related disorders should be examined promptly by an ophthalmologist skilled in binocular indirect ophthalmoscopy and supplementary techniques. [A:III] Patients with retinal breaks or detachments should be treated by an ophthalmologist with experience in the management of these conditions. [A:III] Counseling/Referral Patients at high risk of developing retinal detachment should also be educated about the symptoms of PVD and retinal detachment as well as about the value of periodic follow-up examinations.[a:ii] All patients at increased risk of retinal detachment should be instructed to notify their ophthalmologist promptly if they have a significant change in symptoms, such as a significant increase in floaters, loss of visual field, or decrease in visual acuity. [A:III] Definitions: Ratings of Importance to Care Process Level A, most important Level B, moderately important Level C, relevant but not critical Ratings of Strength of Evidence I. Level I includes evidence obtained from at least one properly conducted, welldesigned randomized, controlled trial. It could include meta-analyses of randomized controlled trials. II. Level II includes evidence obtained from the following: Well-designed controlled trials without randomization Well-designed cohort or case-control analytic studies, preferably from more than one center Multiple-time series with or without the intervention III. Level III includes evidence obtained from one of the following: Descriptive studies 8 of 13

Case reports Reports of expert committees/organization Expert opinion (e.g., Preferred Practice Pattern panel consensus) CLINICAL ALGORITHM(S) None provided EVIDENCE SUPPORTING THE RECOMMENDATIONS TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations.") BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS POTENTIAL BENEFITS When untreated, patients with symptomatic rhegmatogenous retinal detachment will progressively lose vision in the involved eye. There is a substantial economic benefit to society of preventing retinal detachments or limiting their extent, and therefore maintaining the ability of its citizens to read, work, drive, and care for themselves. POTENTIAL HARMS The treatment of peripheral retinal abnormalities can be performed using a variety of anesthesia techniques that include general anesthesia and local (regional) anesthesia (e.g., retrobulbar, peribulbar, periocular, sub-tenon's injection, or topical). Sedation may be used with local anesthesia to minimize pain, anxiety, and discomfort. Complications of periocular injection of anesthesia include hemorrhage and globe perforation. Retrobulbar anesthesia, while not required, has complications that include strabismus, globe perforation, retrobulbar hemorrhage, and macular infarction. Epiretinal membrane proliferation (macular pucker) has been observed after treatment, but the association of treatment with epiretinal membrane formation is uncertain. In one long-term follow-up study, the percentage of eyes developing macular pucker after treatment of retinal breaks was no greater than the percentage of eyes observed to have macular pucker before treatment. In any case, the method of creating a chorioretinal adhesion appears to be unrelated to the incidence of postoperative macular pucker. Extensive cryotherapy can be harmful. QUALIFYING STATEMENTS QUALIFYING STATEMENTS Preferred Practice Patterns provide guidance for the pattern of practice, not for the care of a particular individual. While they should generally meet the 9 of 13

needs of most patients, they cannot possibly best meet the needs of all patients. Adherence to these Preferred Practice Patterns will not ensure a successful outcome in every situation. These practice patterns should not be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed at obtaining the best results. It may be necessary to approach different patients needs in different ways. The physician must make the ultimate judgment about the propriety of the care of a particular patient in light of all of the circumstances presented by that patient. The American Academy of Ophthalmology is available to assist members in resolving ethical dilemmas that arise in the course of ophthalmic practice. Preferred Practice Patterns are not medical standards to be adhered to in all individual situations. The Academy specifically disclaims any and all liability for injury or other damages of any kind, from negligence or otherwise, for any and all claims that may arise out of the use of any recommendations or other information contained herein. IMPLEMENTATION OF THE GUIDELINE DESCRIPTION OF IMPLEMENTATION STRATEGY An implementation strategy was not provided. IMPLEMENTATION TOOLS Patient Resources Personal Digital Assistant (PDA) Downloads Quick Reference Guides/Physician Guides For information about availability, see the "Availability of Companion Documents" and "Patient Resources" fields below. INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES IOM CARE NEED Getting Better Living with Illness IOM DOMAIN Effectiveness Patient-centeredness IDENTIFYING INFORMATION AND AVAILABILITY BIBLIOGRAPHIC SOURCE(S) American Academy of Ophthalmology Retina Panel, Preferred Practice Patterns Committee. Posterior vitreous detachment, retinal breaks, and lattice 10 of 13

degeneration. San Francisco (CA): American Academy of Ophthalmology (AAO); 2003. 17 p. [55 references] ADAPTATION Not applicable: The guideline was not adapted from another source. DATE RELEASED 1998 Sep (revised 2003) GUIDELINE DEVELOPER(S) American Academy of Ophthalmology - Medical Specialty Society SOURCE(S) OF FUNDING American Academy of Ophthalmology GUIDELINE COMMITTEE Preferred Practice Patterns Committee; Retina Panel COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE Retina Panel Members: Emily Y. Chew, MD (Chair); William E. Benson, MD; H. Culver Boldt, MD; Tom S. Chang, MD; Louis A. Lobes, Jr., MD; Joan W. Miller, MD; Timothy G. Murray, MD; Marco A. Zarbin, MD, PhD; Leslie Hyman, PhD (Methodologist) Preferred Practice Patterns Committee Members: Joseph Caprioli, MD (Chair); J. Bronwyn Bateman, MD; Emily Y. Chew, MD; Douglas E. Gaasterland, MD; Sid Mandelbaum, MD; Samuel Masket, MD; Alice Y. Matoba, MD; Donald S. Fong, MD, MPH FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST No proprietary interests were disclosed by members of the Preferred Practice Patterns Retina Panel for the past 3 years up to and including June 2003 for product, investment, or consulting services regarding the equipment, process, or products presented or competing equipment, process, or products presented. GUIDELINE STATUS This is the current release of the guideline. This guideline updates a previous version: American Academy of Ophthalmology (AAO), Preferred Practice Patterns Committee, Retina Panel. Management of posterior vitreous detachment, retinal breaks, and lattice degeneration. San Francisco (CA): American Academy of Ophthalmology (AAO); 1998. 24 p. 11 of 13

All Preferred Practice Patterns are reviewed by their parent panel annually or earlier if developments warrant. GUIDELINE AVAILABILITY Electronic copies: Available from the American Academy of Ophthalmology (AAO) Web site. Print copies: Available from American Academy of Ophthalmology, P.O. Box 7424, San Francisco, CA 94120-7424; telephone, (415) 561-8540. AVAILABILITY OF COMPANION DOCUMENTS The following is available: Summary benchmarks for preferred practice patterns. San Francisco (CA): American Academy of Ophthalmology; 2006 Nov. 21 p. Available in Portable Document Format (PDF) from the American Academy of Ophthalmology (AAO) Web site. Print copies: Available from American Academy of Ophthalmology, P.O. Box 7424, San Francisco, CA 94120-7424; telephone, (415) 561-8540. PATIENT RESOURCES The following patient education brochure is available: Detached and torn retina (1998) Print copies: Available from the American Academy of Ophthalmology (AAO), P.O. Box 7424, San Francisco, CA 94120-7424; Phone: (415) 561-8540. Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content. NGC STATUS This summary was completed by ECRI on February 20, 1999. The information was verified by the guideline developer on April 23, 1999. This summary was updated again on April 30, 2004. The information was verified by the guideline developer May 20, 2004. COPYRIGHT STATEMENT 12 of 13

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. Information about the content, ordering, and copyright permissions can be obtained by calling the American Academy of Ophthalmology at (415) 561-8500. DISCLAIMER NGC DISCLAIMER The National Guideline Clearinghouse (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site. All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies, relevant professional associations, public or private organizations, other government agencies, health care organizations or plans, and similar entities. Guidelines represented on the NGC Web site are submitted by guideline developers, and are screened solely to determine that they meet the NGC Inclusion Criteria which may be found at http://www.guideline.gov/about/inclusion.aspx. NGC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover, the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes. Readers with questions regarding guideline content are directed to contact the guideline developer. 1998-2008 National Guideline Clearinghouse Date Modified: 11/3/2008 13 of 13